


Chief Complaint

by vorpal_platypus



Category: Fire Emblem: Fuukasetsugetsu | Fire Emblem: Three Houses
Genre: Dimitri gets officially diagnosed with PTSD and depression, Gen, Other, that's it that's the fic
Language: English
Status: Completed
Published: 2019-09-16
Updated: 2019-09-16
Packaged: 2020-10-19 16:48:41
Rating: Teen And Up Audiences
Warnings: Creator Chose Not To Use Archive Warnings
Chapters: 1
Words: 1,047
Publisher: archiveofourown.org
Story URL: https://archiveofourown.org/works/20660486
Author URL: https://archiveofourown.org/users/vorpal_platypus/pseuds/vorpal_platypus
Summary: Chief Complaint: "So many loved ones lost… Father. Stepmother. Friends. Allies. I alone can silence their cries for revenge.”History of Present IllnessPatient is a 23 year old male with no known psychiatric history who presents involuntarily, brought in by Byleth for homicidal and suicidal ideation with command auditory and visual hallucinations.





	Chief Complaint

**Author's Note:**

  * For [Metallic_Sweet](https://archiveofourown.org/users/Metallic_Sweet/gifts).

> i literally pulled up UpToDate to look up dosing regimens for the drugs and included ICD-10 diagnostic codes and based this off an actual medical note template given to me by a resident 
> 
> this is how i'm applying my $200,000 degree

**Legal**: Patient is involuntary and capacitated.

**Chief Complaint**: "So many loved ones lost… Father. Stepmother. Friends. Allies. I alone can silence their cries for revenge.”

**History of Present Illness**

Patient is a 23 year old male with no known psychiatric history who presents involuntarily, brought in by Byleth for homicidal and suicidal ideation with command auditory and visual hallucinations.

On interview today, patient appears disheveled, unkempt, and malodorous. Patient was found pacing within the ruins of Gareg Mach Monastery, agitated, guarded, and hostile. Eye contact is intermittent and intense, and patient appears to respond to internal stimuli, at times expressing apologies directed to his dead father. Patient endorses auditory and visual hallucinations of his deceased family, who command him to seek revenge by murdering his step-sister, Edelgard. Per the patient, these hallucinations have been present since the age of 14, when his family and several close friends were assassinated. The patient states he was the only survivor and endorses strong feelings of guilt, saying he cannot be at peace or happy until he has “laid their ghosts to rest”. Alleviating factors include physical combat and companionship from a Dedue Molinaro. Patient indicates symptoms have worsened since the age of 18, when he was overthrown by a coup. Since then, he has been presumed dead, isolated from social support, and pursued by Imperial troops. He endorses further guilt as Dedue appears to have died helping him escape his execution. 

Other depressive symptoms elicited at time of interview include: reduced sleep, irritation and dysphoric mood, loss of interest in other activities, as well as loss of taste and appetite. Though patient does not explicitly endorse suicide ideation, he demonstrates poor judgment and reckless, death-seeking behavior: he attacked a thieves guild on his own and wishes to march an army to the Adrestian capital so that he could “tear off her head and hang it from the gates of Enbarr”. Patient is strongly preoccupied with killing his step-sister, bursting into irritated tangents when asked about other topics. Paranoid delusions that the interviewer was “one of the ghosts returned to haunt me” were elicited. No signs or symptoms of mania were elicited during the interview. Patient denies any recent alcohol or illicit drug use. 

Insight poor. Judgment poor. At present, patient is at high risk of self-neglect, harm to self, and harm to others, and meets criteria for admission at this time.

**Target Symptoms:**

Quality – depression with suicidal, homicidal ideation; psychotic behavior; agitation; aggression 

Duration – years

Timing – constant

** Severity **

Interfering with daily functioning: self-isolating, unable to handle stress of job

Interfering with safety of self or others: evidenced by suicidal and violent behavior

Causing self-neglect: poor hygiene & grooming, not brushing hair/teeth, not bathing

Context – precipitating stressor (framed for avunculicide, deposed from ruling Faerghus after it was conquered, pursued by assassins, has been presumed dead for 5 years)

**Modifying factors:**

Aggravating: homelessness, unemployment, poor social support, legal issues, poor access to health care

Alleviating: physical exercise

Associated signs & symptoms: sleep disturbances, poor appetite, anhedonia

**Past Psychiatric History**

First psychiatric visit: None. 

Previous psychiatric diagnosis: None. 

Previous psychiatric hospitalizations: None.

Current outpatient psychiatrist: None.

Last visit to outpatient psychiatrist: None. 

Past psychiatric medications: None. 

Suicide attempts: None.

Electroconvulsive Therapy: None.

**Current Medications**

Psychiatric: None. 

Psych meds last discharged on: None.

Medical: None. 

Adherence: Not applicable. 

**Allergies**

No known allergies. 

**Past Medical History**

Smallpox, 1170

Fracture of unspecified part of right clavicle, 1173

Keloids on back from lacerations and burns sustained in 1176

**Past Surgical History**

Enucleated left eye, 1181

**Past Trauma History**

Head trauma (Traumatic Brain Injury): Concussion, 1179

Seizures: None.

Loss of consciousness: None. 

Blackouts (substance related): None. 

**Substance Abuse History**

Tobacco: Denies. 

Alcohol: Denies.

Cannabis: Denies. 

Cocaine: Denies. 

Opioids: Denies. 

Benzodiazepines: Denies. 

Amphetamines: Denies. 

Hallucinogens: Denies. 

Detox/Rehab: Denies. 

**Family History**

Mental illness: None.

Suicide attempts: None. 

Substance abuse: None.

Medical problems: None. 

Dementia: None. 

**Psychosocial History**

Family: Patient was born in Fhirdiad and raised by his family.

History of emotional, sexual, and/or physical abuse: Denies. 

Education: Tutored by Gustave Eddie Dominic. Graduate of Gareg Mach. 

Employment status: Unemployed. 

If unemployed, makes ends meet by: looting Adrestian Imperial troops. 

Relationships: None. 

Living Situation: Squatting at Gareg Mach monastery. 

Legal History: Framed for avunculicide and publicly executed. 

**Medical Review of Systems**

Constitutional: headache

Ear, Nose, Throat: denies sore throat or congestion

Cardiac: denies chest pain or palpitations

Pulmonary: denies cough or shortness of breath 

Gastrointestinal: denies diarrhea or constipation

Genitourinary: denies dysuria or hematuria

Endocrine: denies polydipsia or polyuria 

Musculoskeletal: denies myalgias

Skin: denies rashes

Neurological: denies tremors or paraesthesias

**Vitals**

T: 37.5 C 

Heart Rate: 62 beats per minute

Blood Pressure: 112/75 mmHg

Respiration Rate: 12 breaths per minute

**Laboratory Results**

Within normal limits. 

**Diagnostic Imaging**

Not applicable. 

**Mental Status Exam**

Appearance/Behavior: appears stated age, unkempt, malodorous / guarded, defensive, hostile

Orientation: awake, alert, oriented to person, place, and time

Speech: clear, coherent, normal rate and rhythm

Eye Contact: intermittent, intense

Motor Activity: psychomotor agitation, no dystonic/tardive movements

Mood/Affect: dysphoric / labile 

Thought Process: coherent, logical, goal-directed

Thought content: 

\- Hallucinations: endorses auditory and visual hallucinations of dead loved ones commanding him to murder his step-sister, appears to respond to internal stimuli

\- Delusions/Preoccupations: paranoid delusions that living people are patient is pre-occupied with killing his step-sister

\- Suicidal/Homicidal ideation: patient endorses homicidal ideation towards his step-sister

Insight/Judgment: poor/poor

Attention/Concentration: attentive to interview

Memory: appears grossly intact

**Assessment**

Post Traumatic Stress Disorder 309.81

Major Depressive Disorder, recurrent episode, with psychotic features 296.34

rule out Schizoaffective Disorder, Depressive Type 295.70

**Plan**

1) Legal Status: patient is involuntary and capacitated. 

2) Patient continues to require 24 hour observation, nursing care, and inpatient treatment and cannot be treated in a less restrictive environment. 

3) Medications: 

Prazosin 1 mg at bedtime 

Sertraline 25 mg daily 

Resperidone 0.5 mg twice daily 

4) Tobacco Cessation: Non-Smoker 

5) Nursing Orders: encourage compliance with treatment plan. 

6) Labs/Imaging: None. 

7) Consults: None. 

9) Social Work: evaluation for disposition and follow-up.

Patient was educated about reasons for prescribing the above medications, expected benefits and likelihood of clinical improvement, as well as potential side effects and relevant risks; discussed treatment alternatives, expected course without treatment, and results of not receiving care. Will continue to build therapeutic alliance and monitor.

**Author's Note:**

> REMEMBER KIDDOS if you are experiencing at least 5 of the following: 
> 
> -Sleep disturbances  
-Loss of interest in hobbies or usual activities  
-Guilt  
-Low energy  
-Problems with concentration  
-Appetite changes  
-Moving more slowly, like movement feels like a chore to perform  
-Suicidal thoughts 
> 
> In addition to low mood (feeling sad) and anhedonia (inability to feel pleasure), you may have clinical depression. Go see a doctor and get some Citalopram or other SSRI to take for at least 6 weeks.


End file.
